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Chapter 2The Pretravel Consultation

Perspectives: Prioritizing Care for the Resource-Limited Traveler

Zoon Wangu, Elizabeth D. Barnett

Travelers seen in pretravel clinic consultations often have financial constraints. Prioritizing immunizations and prophylactic medications should be part of an individualized assessment based on the travel itinerary, efficacy and safety of vaccines and medications, and associated costs. Travelers must often pay out of pocket for pretravel care, as many health insurance plans do not cover travel immunizations or prophylaxis. As an example, the estimated cost of a US pretravel consultation for a backpacker planning a 4-week trip to West Africa may be as high as $1,400 for the initial consultation and vaccinations, excluding malaria chemo-prophylaxis. Travelers with limited budgets may be at higher risk for travel-associated infections, as they often visit remote areas, stay in lower-grade accommodations, and are more likely to eat local street food. Therefore, the cost of disease (such as malaria) may, in many cases, outweigh costs of vaccination and prophylaxis. The financial benefits of obtaining travel health insurance and evacuation insurance before travel must also be considered (see Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance later in this chapter). Clinicians need to understand travelers’ financial constraints in order to provide realistic recommendations. The variety of insurance plans, number of travelers without adequate insurance coverage, and number of student and budget travelers challenges even the most savvy travel medicine clinicians. This section provides guidance for busy practitioners in prioritizing vaccine and prophylaxis choices.

VACCINES

Required Vaccines

Only 2 vaccines are required categorically for some travelers: meningococcal vaccine for pilgrims traveling to Mecca during the Hajj and yellow fever vaccine for travelers to certain countries in Africa and South America (see Chapter 3, Yellow Fever & Malaria Information, by Country). If either of these vaccines is required for an itinerary, prioritize it since the traveler may be denied entry to the country without proof of vaccination. Note that travelers who may be staying in a yellow fever– endemic country only briefly (such as during an airport layover) may still need evidence of vaccination to enter other countries on their itinerary. In a few specific circumstances, travelers to countries that are exporting polio may be asked to show proof of polio vaccination before they are allowed to leave those countries if they have spent >4 weeks in the country (see Chapter 3, Poliomyelitis).

Routine Vaccines

All travelers should be up-to-date with routine vaccines before international travel, regardless of destination. The benefits of vaccines extend beyond the travel period, and in many cases lifelong immunity is achieved. Routine vaccines are generally associated with lower costs, since they are mass-produced as part of the scheduled national childhood and adult vaccination programs, and many health insurance plans will reimburse the patient for the cost of vaccine administration. If cost of routine vaccines is a limitation, a traveler can explore opportunities for obtaining them in a health department or primary care setting, where cost may be lower than in a travel clinic. Prioritize the routine vaccines that protect against diseases for which the traveler is most likely to be at general risk. At this time, top priorities for most destinations would include vaccines against influenza, measles, and hepatitis A and B.

Some travelers may be immune to the disease for which immunization is being considered. Testing for antibody concentrations may be covered by insurance when vaccines are not. Testing for immunity to diseases such as measles, varicella, and hepatitis A and B can help determine whether vaccination is needed.

Recommended Vaccines

Consider time until departure, risk of disease at the destination, effectiveness and safety of vaccine, and likelihood of repeat travel. For example, parenteral typhoid vaccine may be less cost-effective for certain travelers (especially when departures are imminent and trip duration is short) because of the relatively low efficacy, short duration of protection, and time needed for onset of protection (≥2 weeks). On the other hand, oral typhoid vaccine has a longer duration of protection, and time to protection is shorter, approximately 1 week.

When considering rabies vaccine for resource-limited travelers, consider the risk of animal exposure, access to local health care, and availability of rabies immune globulin and rabies vaccine at the traveler’s destination. Travelers who decline preexposure immunization should have a plan of action if an exposure occurs. In up to 37% of locations worldwide, rabies vaccine or immune globulin are available only sometimes or never.

Review the itinerary in detail to determine the need for Japanese encephalitis vaccine. Some travelers may be able to obtain vaccine at lower cost outside the United States. Those who decline vaccine should have a clear understanding of when and how to use insect repellents and other measures to prevent mosquito bites.

MALARIA CHEMOPROPHYLAXIS

Every pretravel consultation should include detailed advice about preventing mosquito bites (see Protection against Mosquitoes, Ticks, & Other Arthropods later in this chapter). Malaria chemoprophylaxis, if needed, should be offered based on the risk profile of the traveler, taking into account possible financial burden. The risk of acquiring malaria varies widely, depending on destination, accommodations, and activities during travel. Malaria risk is decreasing in many countries, and up-to-date sources of risk areas in the destination country should be used to advise travelers. Costs associated with the different regimens vary widely. For example, based on current prices in the United States, a prophylactic treatment course for a 3-week trip to a malaria-endemic destination would cost $120–$250 for doxycycline, $50–$100 for chloroquine, $95–$120 for mefloquine, and $200–$225 for atovaquone-proguanil (depending on health insurance and other factors). Atovaquone-proguanil cost may be equivalent to that of mefloquine for short trips, but mefloquine (or chloroquine, in the few regions where malaria remains susceptible) will be more cost- effective for trips lasting ≥2 weeks. Travelers who raise the question of purchasing antimalarial drugs at their destination must be advised about the risk of inappropriate, substandard, and counterfeit medications and discouraged from this practice (see Perspectives: Pharmaceutical Quality & Falsified Drugs later in this chapter).

PREVENTIVE BEHAVIORS

Educate about alternative ways to reduce risk, especially when immunization is not possible. For example, advise travelers to avoid animal bites, use insect precautions, and observe food and water precautions to the best of their ability.

Budget travelers and those who cannot afford travel vaccines will continue to challenge travel medicine practitioners. All travelers can benefit from multiple strategies to safeguard their health during travel, in addition to vaccination and prophylaxis. These strategies include following safety (especially road traffic safety) and security guidelines, observing sun protection, avoiding food hazards, and following safe sex practices. Following insect precautions is essential to prevent dengue and chikungunya viruses and has become especially pertinent with the emergence of Zika virus in Latin America. Travelers can be reassured that the actions they take to avoid these preventable hazards may, in the long run, protect against travel-associated risks that are more prevalent than are certain vaccine-preventable diseases.

Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official recommendations contained in the book. The views and opinions expressed in this section are those of the authors and do not necessarily represent the official position of CDC.